Provider Demographics
NPI:1629295274
Name:CORNERSTONE FAMILY & COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:CORNERSTONE FAMILY & COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-634-5255
Mailing Address - Street 1:PO BOX 1496
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:208-634-5255
Mailing Address - Fax:208-634-1047
Practice Address - Street 1:143 EAST LAKE STREET
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:208-634-5255
Practice Address - Fax:208-634-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3826122300000X
IDD3280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1913080OtherUNITED CONCORDIA
ID000010155075OtherDR. NEWTON REGENCE BS
ID00001156002OtherDR ELLIOTT REGENCE BS
ID6P003OtherDR. NEWTON BC BS
ID6P005OtherDR ELLIOTT BC BS